of Corona or COVID-19 or SARS-CoV-2 Achtergrond Corona Viral - - PowerPoint PPT Presentation

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of Corona or COVID-19 or SARS-CoV-2 Achtergrond Corona Viral - - PowerPoint PPT Presentation

Apr 25, 2023 455 likes •700 views

of Corona or COVID-19 or SARS-CoV-2 Achtergrond Corona Viral infection Symptoms: Fever, headache, malaise Cough, SILENT HYPOXEMIA, shortness of breath Common cold, sneez Reduced sense of smell or taste Diarrea,

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  • f Corona
  • r

COVID-19

  • r

SARS-CoV-2

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SLIDE 2

Achtergrond Corona

  • Viral infection
  • Symptoms:

– Fever, headache, malaise – Cough, SILENT HYPOXEMIA, shortness of breath – Common cold, sneez – Reduced sense of smell or taste – Diarrea, abdominal complaints, anorexia

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Infection

  • Via aerosol
  • Surface is only infectious for a short time
  • Unknown: faecal infection
  • Not aerogene!!!

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PPE

  • Source isolation OR isolation from environment

– Irrational and waste of PPE – Severe cough will lead to spread of the virus – NRM / nebulizers causes aerosols (N95 /FFP1-2)

  • Infection through mucosa

– Nose / mouth / eyes – Mouth-nose mask, goggles OR faceshield

  • Minimal infection through surface / aerosol

– Handhygiene and apron (to protect from cough) – Alcohol is enough – Virus dies quickly – Few viral particles on surfaces

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  • Pregnancy:

– In case series no increased risk for complicated disease course – Most studies without pregnant/lactating women – No contra-indication lactation – COVID+: perform good handhygiene and use mask during lactation

  • Children

– Mild disease course – Rare: hyperinflammatory syndrome / Kawasaki-like

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Diagnostics

  • PCR

– Nasopharynx – Feces

  • CT-scan: typical abnormalities
  • Lab

– Lymfopenia – Inflammation: CRP, ferritine, D-dimeer – LDH

  • Gastro-intestinal complaianst sometimes severe, diagnostics not useful
  • Serology

– Unknown what is the value of positieve immunology – No routine lab test

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Clinical course

  • Incubation: median 5-7 days

– Upto 14 days

  • 0-7 days: viremia

– Complaints of a viral respiratory tract infection

  • After 7-10 days often worsening occurs

– Pulmonary embolus – Immuno dysregulation – Viremia has gone down by now – Indication for the start of steroid therapy

  • 80% asymptomatic – mild course

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Treatment

  • There is no curative treatment available

– Chloroquine – Hydrochloroquine – Remdesivir – Steroids

  • Supportive care

– OXYGEN – Nebulisation not standard required and harmful due to aerosol – Keep patients relatively dry – Anticoagulant therapy – Accept anorexia in early fase

  • Bacterial superinfections are rare in 0-14 days

– In ICU watch out for central venous cathere infections and ventilatr associated pneumonia (VAP)

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Remdesivir

  • Binds RNA transciptase with premature ending

transciption (thus preventing replication)

  • In vitro and in vivo effect on MERS-CoV en SARS-

CoV-2 reducing viremia en and lung tissue damage

  • Adaptive COVID-19 Treatment Trial (ACTT)

– Multinational, randomized, placebo-controlled – Severely ill: reduced time to recovery – Effect most clear in NON intubated patients – No effect in intubated patients or in mild disease

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Steroids (dexamethason)

  • Unpublished data (RECOVERY studie)

– Randomised, open label, multicenter UK – Admitted patients – Dexamethason vs standard care – Lower mortality in dexa group

  • Severe patients (O2 suppletion)
  • Larger effect in IC patients
  • No effect in patients without O2 suppletion
  • Unclear what er the exposure risks

– Disadvantages – Influence on the course of viremia – Time of start dexa – Trial studied both suspected and confirmed patients

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RECOVERY trial

  • Different treatment strategies vs standard care

– 6425 participants in preliminary analysis

  • 2104 dexa-group
  • 4321 control group, 7% cross over dexa

– “a few” HCL, lopinavir/ritonavir, remdesivir. Tocilizumab

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  • Skewed age distribution

ventilated patients mostly <70 yrs >80 yrs rarely 1% ventilated

  • Very few pregnant women and children
  • Treating physician allowed to issue a contra

indication for steroids. In that case the patient was not randomised for steroids

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Downside of steroids

  • Steroids may exacerbate late infections
  • Steroids may decrease clearance of the virus

Steroid cause hyperglycemia and fluid retention

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Hydrochloroquine

  • Increase endosomal pH, virus cannot fuse with

host-cel

  • retrospective studies
  • Bias in treating only the most severely ill patients
  • RCT’s underpowered
  • Lancet publication with unreliable data

(withdrawn)

  • No evidence for effectiveness, a lot of side

effects.

  • NOT standard treatment

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Complications

  • COVID worsening

– Fever (peaks) – Desaturation, tachypnea, HYPOXEMIE – Increase in X ray abnormalities – Knowing the clinical course very important

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Pulmonary Embolus (PE)

  • 17% ICU pt have PE despite profylaxis
  • No deep venous calf thrombosis, origin is in lung

cirulation

  • Not clear how many complications happen using

standard therapeutic anticoagulation

  • Diagnostics limited

– Clinical picture: thoracic pain, sudden worsening (pulmonary or hemodynamically) – ECG – Difficult to differentiate from COVID progression / hyperinflammation – D-dimer

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Complications

  • Hyperhydration / ARDS

– Endothelial leakage – Exacerbated by increased volume therapy – AFib with congestive heart failure

  • Hypertension / diabetes:

– Glucose curves – Dehydration/ keto-acidosis with clinical picture of increasde respiratory failure (Kussmaul)

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Deterioration / Assessment at ward

  • ABCDE – OXYGEN

– RR >20 – Desaturation <95%

  • Be alert = control in 30 minutes
  • Be alert to prevent fast deterioration / exhaustion
  • Fever

– Take bloodcultures – Sputum cultures (non ICU) not usefull – Procalcitonine (PCT when in doubt – NO standardized antibiotic therapy – IF you start antibiotics: stop if cultures are > 72 hs negative, low PCT

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ABCDE

  • A: spontaneous breathing, talks
  • B: saturation, resp frequency, work of breathing
  • C: bloodpressure, pulse, diuresis, fluid balance
  • D: glucose, consciousness, delirium
  • E: temp, gastro-intestinal
  • Medication, stimulate mobilisation

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  • Admission on the ward:

– Always evaluate the patient by yourself – Have nurse check vital parameters – Transport may lead to clinical wordening – Walk through the flow chart! – Re-evaluate pt

  • 30 min after adaptation of O2
  • 1 hour after insulin administration
  • Confer with internist lwhen in doubt!!

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  • Rounds:

– Use ABCDE methodology – Make sure to have vitals ready before the start – Make sure nusre is present during the rounds with you Practice NOW to be prepared LATER

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